Health Insur & Auth Coord IV

As a community, the University of Rochester is defined by a deep commitment to Meliora - Ever Better. Embedded in that ideal are the values we share: equity, leadership, integrity, openness, respect, and accountability. Together, we will set the highest standards for how we treat each other to ensure our community is welcoming to all and is a place where all can thrive.

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The referenced pay range represents the minimum and maximum compensation for this job. Individual annual salaries/hourly rates will be set within the job's compensation range, and will be determined by considering factors including, but not limited to, market data, education, experience, qualifications, expertise of the individual, and internal equity considerations.

Responsibilities:

ESSENTIAL FUNCTIONS

• Creates a professional and effective customer-oriented environment by obtaining pertinent demographic information, explaining insurance benefits and limits, informing patients of the anticipated costs of services, patient liability, and patient responsibilities, explaining billing policies, and discussing financial options. Advises and guides patients on switching insurance carriers, when applicable, to ensure the best coverage for both patient and hospital/provider reimbursement. Assists patients and their family with insurance questions and resolution of billing issues. Performs crisis intervention when financial issues arise pre- and post-treatment.
• Obtains benefits and pre-certification along with all other billing requirements. Maintains updated knowledge of hospital contract for in and out-of-network payers. Identifies non-covered hospital services, inquires how the financial obligation will be met, analyzes patient’s financial status and advises patient on the best course of action for payment. Prepares financial packets based on each individual patient’s benefits, financial interview, and calculated estimated expenses. Communicates with Clinical teams to obtain treatment plans and discharge planning to begin the insurance verification process. Processes clinical information required by third party payers in a timely manner. Updates relevant electronic medical records with financial and insurance information on all potential candidates and transplant recipients. Analyzes, organizes, and utilizes complex data and rules related to contracting and patient benefits to provide financial clearance. Set up visits in electronic medical record for anonymous donors who come to SMH for donation. Creates Transplant and Donor guarantors with accompanied bundled billing episodes. Identifies global/bundled billing episode, terms, period in which it is valid, and notifies appropriate URMC parties. Reviews, analyzes and acts upon discrepancies prior to billing. Refers cases to leadership when additional coverage is necessary. Resolves Medicare coordination of benefits discrepancies, as well as prescription coverage issues with Social Security Administration, for reinstatement of benefits.
• Oversees a caseload of patients on the wait list and maintains case files in accordance with current state, federal and agency rules. Maintains weekly status of all pending cases and take appropriate action to resolve them. Processes referrals to financially screen potential candidates. Performs monthly re-verification of insurance coverage for waitlisted patients. Responsible for re-approvals when patient approaches approval expiration. Monitors patients to ensure timely application for Medicare, by the end of the 30-month coordination period. Reviews the top 10 liver patients by blood type and updates the liver database with insurance and authorization timeframe.
• Reviews Medicare for MSP questions and validations. Ensures compliance with the Office of the Inspector General guidelines by notifying patients of exhausting Medicare benefits and the option to utilize lifetime reserve days. Ensures appropriate documentation is on file for assigned caseload. Obtains all required signatures for payment of hospital services. Ensures patients are financially cleared following UNOS requirements and documentation listed in EPIC. Maintains a thorough knowledge of insurance carriers’ policies and benefit levels as it relates to each specialty.
• Works closely with clinical teams in Solid Organ and BMT/CAR-T. Alerts the clinical team of any issues that may impact patient’s ability to undergo the procedure. Works collaboratively with clinical team on authorization denials and inquires on appeal process with the insurance payer. Attends weekly selection committee meetings. Attends quarterly billing meetings to discuss pharmacy, insurance coverage and/or billing problems. Attends the annual educational Transplant Financial Conference on rotation. Monitors and participates in Transplant Financial Coordinator national email listserv. Trains other staff, as assigned by management.
• Other duties as assigned.

MINIMUM EDUCATION & EXPERIENCE

• High School diploma or equivalent and 3 years of related experience required
• Associate's degree preferred
• Or equivalent combination of education and experience

KNOWLEDGE, SKILLS AND ABILITIES

• High degree of professionalism and motivation with excellent written and verbal communication and customer service skills required
• Ability to work independently, as well as in a team environment required
• Flexibility to be on call and work other assigned hours, weekends required
• Extensive knowledge and comprehension of ICD-10 and CPT coding, medical terminology, and insurance standards and regulations preferred
• Strong computer skills and ability to type 45 words per minute preferred

LICENSES AND CERTIFICATIONS

• Position may be subject to membership and certification with the Transplant Financial Coordinators Association upon hire preferred

The University of Rochester is committed to fostering, cultivating, and preserving an inclusive and welcoming culture to advance the University’s Mission to Learn, Discover, Heal, Create – and Make the World Ever Better. In support of our values and those of our society, the University is committed to not discriminating on the basis of age, color, disability, ethnicity, gender identity or expression, genetic information, marital status, military/veteran status, national origin, race, religion, creed, sex, sexual orientation, citizenship status, or any other characteristic protected by federal, state, or local law (Protected Characteristics). This commitment extends to non-discrimination in the administration of our policies, admissions, employment, access, and recruitment of candidates, for all persons consistent with our values and based on applicable law.